Peripherally inserted central catheter complications versus midline catheter complications: A systematic review

Article Type : Reviews

Authors

1 Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran

2 Burn and Regenerative Medicine Research Center, Guilan University of Medical Sciences, Rasht, Iran

3 Student Research Committee, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran

Abstract

The purpose of this systematic study is to compare the risks associated with peripherally inserted central catheters (PICC) and midline catheters (MC). International electronic databases like Scopus, PubMed, and Web of Science were searched systematically from the earliest date to December 13, 2022, using keywords extracted from Medical Subject Headings like "Peripheral catheterization", "Peripherally inserted central catheter", and "Midline catheter". Additionally, Iranian databases like Iranmedex were looked up. The cross-sectional study appraisal tool (AXIS tool) was used to evaluate the quality of the studies that were a part of this review. In total, 12,526 patients participated in five cross-sectional studies. Of the participants, 52.33% were male. Participants had 7,594 PICCs and 6,712 MCs. The complications of PICC in patients included deep vein thrombosis (DVT) (2.34%), occlusion (4.02%), infection (positive culture) (2.02%), leakage (0.52%), pain (3.09%), dislodgment (2.54%), phlebitis (0.73%), thromboembolism (0.12%), bleeding (3.09%), fracture/broke (1.03%), nonpatent (1.46%), and local event (10.00%). Also, MC complications included DVT (3.91%), occlusion (2.65%), infection (positive culture) (0.96%), leakage (4.40%), pain (2.70%), dislodgment (5.96%), phlebitis (1.68%), infiltration (5.91%), thromboembolism (1.30%), bleeding (1.73%), fracture/broke (0.86%), nonpatent (8.50%), edema (0.50%), and local event (10.97%). The rate of infection and occlusion was higher in PICC. While the rate of thrombosis was higher in MC. Therefore, the healthcare team, especially nurses, can reduce the rate of complications by carefully preparing the skin, using aseptic techniques, and taking care of the catheter site.

Keywords

1 Introduction

One of the key procedures in delivering medical and nursing care for hospitalized patients is establishing and maintaining intravenous access. On the other hand, for patients who are going to be hospitalized for a long time, a team is formed for vascular access and placement of the vascular access device [1, 2]. Central catheters known as peripherally inserted central catheters (PICC) are put into a patient's vein under ultrasound guidance. These catheters are usually used for patients whose veins are difficult to access. On the other hand, these patients usually need long-term central and peripheral infusion treatments [3]. Even while these catheters are a good option for a certain subset of patients, they can still malfunction, cause bloodstream infections associated with the catheter, cause venous thrombosis, and be very expensive [4].

PICCs can often be a less desirable option for peripheral infusions than midline catheters (MCs).  These catheters enter the arm's peripheral veins and exit just before the axillary veins [5]. These catheters do not have the same danger of bloodstream infection as central lines because they end in peripheral veins [6]. But with the increasing number of MCs, there is concern about their complications and premature failure [7]. Among these complications, we can mention thrombosis. PICCs can generally be used for prolonged venous access. In contrast to MCs, which are typically utilized for short-term therapies, this long-term access to the veins can be used for whole parenteral nutrition, chemotherapy, and antibiotic therapy. On the other hand, as said, each of them has complications [8]. According to a study conducted in the USA, MCs have a lower incidence of blood infection and blockage than PICCs [9]. According to a different study conducted in the USA, MCs have a higher risk of thrombosis than PICCs [10].

The safety of PICCs and MCs has been compared in studies. However, as far as we are aware, no study has thoroughly examined and evaluated the publications contrasting the safety of these two different types of catheters. This systematic review was carried out to look at the complications of the PICCs compared to the MCs because of the significance of the topic and the conflicting results about the safety of these two catheters.

 

2 Methods

2.1 Study registration and reporting

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist served as the basis for the processes used to perform this systematic review [11]. Additionally, the international prospective register of systematic reviews (PROSPERO) database does not have a record of this systematic review.

 

2.2 Search strategy

International electronic databases like Scopus, PubMed, and Web of Science were searched systematically from the earliest date to December 13, 2022, using keywords extracted from Medical Subject Headings like "Peripheral catheterization", "Peripherally inserted central catheter", and "Midline catheter". Additionally, Iranian databases like Iranmedex were looked up. For example, the search strategy was in PubMed/MEDLINE database including ((“Peripheral catheterization”) OR (“Peripherally inserted central catheter”) OR (“PICC”)) AND ((“Midline catheter”) OR (“MC”)) AND ((“Complication”) OR (“Safety”)). To combine terms, the Boolean operators "OR" and "AND" were employed. The Persian equivalent of the aforementioned keywords was used to search Persian electronic databases. Two researchers independently carried out the systematic search process. This review study excludes gray literature, which includes expert comments, conference presentations, dissertations, research and committee reports, and ongoing research. Gray literature refers to articles that have been published electronically but have not been reviewed by a for-profit publisher [12].

 

2.3 Inclusion and exclusion criteria

This systematic review examined cross-sectional studies on the safety of MCs versus PICCs that were published in English and Persian. Research with qualitative designs, reviews, case reports, conference proceedings, letters to the editor, and experimental studies was excluded.

 

2.4 Study selection

The searched articles were examined using EndNote 20 software. Two researchers independently evaluated the papers using the inclusion and exclusion criteria of this study. Article titles, abstracts, and full texts were hand-reviewed after the initial electronic review, which also involved the removal of duplicate studies. The third researcher was enlisted to assist in mediating potential disputes between the first two researchers. Finally, the sources underwent a thorough examination to prevent the loss of information.

 

2.5 Data extraction and quality assessment

The appraisal technique for cross-sectional studies was used to assess the quality of the studies that were included in this review (AXIS tool). This test uses 20 elements using a two-point Likert scale, encompassing yes (score of 1) and no (score of 0), to assess the quality of the included research (score of 0). This instrument evaluates study design quality (7 items), report quality (7 things), and potential bias introduction (6 items). The quality of studies is rated by AXIS on a scale of high (70 to 100%), fair (60 to 69.9%), and low (0 to 59.9%) [13]. Two researchers independently collected data and assessed the studies' quality.

 

3 Results

3.1 Study selection

As shown in Figure 1, a comprehensive search of electronic databases yielded 1,724 studies. Due to duplicate articles, 503 articles were excluded from the study. Out of the remaining 1,221 papers, 1,106 articles were disqualified from this systematic review because they did not support the objectives of the study, and 84 studies were disqualified because they were not cross-sectional. Following a thorough analysis of the publications' full texts, fifteen research were discarded for having inadequate methods or outcomes, and seven studies were discarded for not having enough data. Finally, five studies [9, 10, 14-16] remained in this systematic review.

 

3.2 Study characteristics

As mentioned in Table 1, in total, 12,526 patients participated in five cross-sectional studies. Of the participants, 52.33% were male. Participants had 7,594 PICCs and 6,712 MCs. The publications that made up this systematic review were carried out in the USA (n=4) [9, 10, 14, 16], and Australia (n=1) [15].

Figure 1. Flow diagram of the study selection process.

Figure 2. Assessment of the quality of the included articles.

 

3.3 Methodological quality of included papers

Figure 2 exemplifies the high standard of all the research [9, 10, 14-16] included in this systematic review. Two research [15, 16] also failed to disclose their funding sources or potential conflicts of interest.

 

3.4 Complications of PICC and MC

As mentioned in Table 1, the complications of PICC in patients included deep vein thrombosis (DVT) (2.34%, n=4) [9, 10, 15, 16], occlusion (4.02%, n=3) [9, 14, 15], infection (positive culture) (2.02%, n=3) [9, 14, 16], leakage (0.52%, n=2) [15, 16], pain (3.09%, n=2), dislodgment (2.54%, n=2) [14, 15], phlebitis (0.73%, n=2) [15, 16], infiltration (0%, n=2) [14, 16], thromboembolism (0.12%, n=2) [9, 14], bleeding (3.09%, n=1) [15], fracture/broke (1.03%, n=1) [15], nonpatent (1.46%, n=1) [16], edema (0%, n=1) [16], and local event (10.00%, n=1) [14]. Also, MC complications included DVT (3.91%, n=4) [9, 10, 15, 16], occlusion (2.65%, n=3) [9, 14, 15], infection (positive culture) (0.96%, n=3) [9, 14, 16], leakage (4.40%, n=2) [15, 16], pain (2.70%, n=2), dislodgment (5.96%, n=2) [14, 15], phlebitis (1.68%, n=2) [15, 16], infiltration (5.91%, n=2) [14, 16], thromboembolism (1.30%, n=2) [9, 14], bleeding (1.73%, n=1) [15], fracture/broke (0.86%, n=1) [15], nonpatent (8.50%, n=1) [16], edema (0.50%, n=1) [16], and local event (10.97%, n=1) [14].

 

3.5│ Comparison of complications between PICC and MC

As mentioned in Table 1, in one study [9], the complication rate was higher with PICC. However, in another study [16], the rate of complications was higher in MC. The rate of infection and occlusion was higher in PICC [9]. While the rate of thrombosis was higher in MC [10].

 

4 Discussion

The current systematic review included five studies and 12,526 patients, which examined the complications of PICC and MC and compared them. In general, the results had heterogeneity. Complications in patients with PICC and MC included DVT, occlusion, infection (positive culture), leakage, pain, dislodgment, phlebitis, infiltration, thromboembolism, bleeding, fracture/broke, nonpatent, edema, and local event.

A rising number of critically ill patients in diverse disease states, clinical settings, and for a variety of purposes require venous access devices [17]. Their two different types are PICC and MC. The use of these catheters is necessary in some cases, but they may have complications [18]. In this study, the difference in complications of patients with PICC and MC had heterogeneity.

The combined consequences of thromboembolism and infection were shown to be the most frequent in PICC, according to the findings of a systematic review and meta-analysis on expectant mothers with PICC in the United States. Although, in general, there was significant heterogeneity among the results included in this study [19]. The most frequent PICC consequences in burn patients were infection and DVT, according to a retrospective cohort review research [20]. According to the findings of a different study, a small and insignificant proportion of patients receiving care in intensive care units had infections and DVTs at the PICC site [21].

The results of a two-year study on infection in people with MC showed that there was no infection in the catheter path and blood flow in MC. Also, the most common complication in this catheter was dislodgment [22]. The results of a systematic review regarding MC complications showed that the infection rate was 0.28 per 1,000 catheters per day. Dislodgement, DVT, and occlusion were also the most common complications [23].

The results of this systematic review showed that the rate of infection and occlusion was higher in PICC than in MC. Also, the amount of thrombosis in MC was higher than in PICC. In general, due to the existence of high heterogeneity in the studies in this systematic review, it is not possible to conclude that the rate of complications is higher in which of the methods. Therefore, it is suggested to investigate the complications in PICC and MC in future studies and compare them with each other.

 

4.1 Limitations

Just like any other systematic review, this one had some limitations. This systematic review did not allow for the performance of a meta-analysis. A lack of meta-analysis may result in less accurate data analysis and more erratic results. A methodical approach to data collecting, organizing, and research analysis continued in this study even if a meta-analysis was not used. It is probable that not all studies on this topic were located despite a thorough database search. Finally, this systematic review only includes research that was written in English and Persian; it is likely that studies that were written in other languages were overlooked.

 

4.2 Implications for healthcare workers

One of the important complications in PICC and MC is infection. The healthcare team, especially nurses, can reduce the rate of infection by carefully preparing the skin, using aseptic techniques, and taking care of the catheter site.

 

4.3 Recommendations for future research

More research on the comparison of complications in PICC and MC is advised because of the heterogeneity in the study outcomes.

 

Table 1. Basic characteristics of the included studies in this systematic review.

First Author/year

Location

Sample size

M/F ratio (%)

PICC (%)

MC (%)

Key results

AXIS Score

Sharp et al., 2014 [15]

Australia

64

60.94/39.09

97 (29.57%)

231 (70.43%)

·   The rate of complications in PICC was as follows:

o DVT: 0%

o Occlusion: 1.03%

o Bleeding: 3.09%

o Leakage: 1.03%

o Pain: 6.18%

o Dislodgment: 3.09%

o Fracture/broken: 1.03%

o Phlebitis: 0%

·   The rate of complications in MC was as follows:

o DVT: 1.30%

o Occlusion: 3.46%

o Bleeding: 1.73%

o Leakage: 7.79%

o Pain: 3.90%

o Dislodgment: 2.16%

o Fracture/broken: 0.86%

o Phlebitis: 0.86%

High

Xu et al., 2016 [16]

USA

367

N/A

206 (50.74%)

200 (49.26%)

·    The rate of complications in PICC was as follows:

o DVT: 0.97%

o Leakage: 0%

o Pain: 0%

o Phlebitis: 1.46%

o Positive culture: 2.43%

o Infiltration: 0%

o Nonpatent: 1.46%

o Edema: 0%

·   The rate of complications in MC was as follows:

o DVT: 1.00%

o Leakage: 1.00%

o Pain: 1.50%

o Phlebitis: 2.50%

o Positive culture: 2.50%

o Infiltration: 4.50%

o Nonpatent: 8.50%

o Edema: 0.50%

·      There was a significant difference between the complications of PICC and MC (P<0.001), and the rate of complications was higher in MC.

High

Bahl et al., 2019 [10]

USA

1100

N/A

1483 (57.55%)

1094 (42.45%)

·   The rate of thrombosis complication in PICC was 6.88%.

·   The rate of thrombosis complication in MC was 11.88%.

·   There was a significant difference between the thrombosis complications of PICC and MC (P<0.001), and the rate of complications was higher in MC.

High

Seo et al., 2020 [14]

USA

132

48.89/51.11

50 (39.26%)

82 (60.74%)

·      The rate of complications in PICC was as follows:

o  Local event: 10.00%

o  Dislodging: 2.00%

o  Infiltration: 0%

o  Occlusion: 4.00%

o  Thromboembolism: 0%

o  Infection: 2.00%

·      The rate of complications in MC was as follows:

o  Local event: 10.97%

o  Dislodging: 9.75%

o  Infiltration: 7.32%

o  Occlusion: 2.44%

o  Thromboembolism: 2.44%

o  Infection: 0%

High

Swaminathan et al, 2021 [9]

USA

10863

47.15/52.85

5758 (53.00%)

5105 (47.00%)

·      The rate of complications in PICC was as follows:

o  Occlusion: 7.03%

o  Embolism: 0.24%

o  Infection: 1.62%

o  DVT:1.49%

·      The rate of complications in MC was as follows:

o  Occlusion: 2.06%

o  Embolism: 0.16%

o  Infection: 0.37%

o  DVT: 1.45%

There was a significant difference between the infection complications of PICC and MC (P<0.001), and the rate of complications was higher in PICC.

There was a significant difference between the occlusion complications of PICC and MC (P<0.001), and the rate of complications was higher in PICC.

There was a significant difference between the complications of PICC and MC (P<0.001), and the rate of complications was higher in PICC.

High

 

5 Conclusions

In sum, the current systematic review included five studies and 12,526 patients, which examined the complications of PICC and MC and compared them. In general, the results had heterogeneity. Complications in patients with PICC and MC included DVT, occlusion, infection (positive culture), leakage, pain, dislodgment, phlebitis, infiltration, thromboembolism, bleeding, fracture/broke, nonpatent, edema, and local event. Therefore, the healthcare team, especially nurses, can reduce the rate of complications by carefully preparing the skin, using aseptic techniques, and taking care of the catheter site.

 

Acknowledgements

Not applicable.

 

Authors’ contributions

Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work: AF, AA, MH, PT; Drafting the work or revising it critically for important intellectual content: AF, AA, MH, PT; Final approval of the version to be published: AF, AA, MH, PT; Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: AF, AA, MH, PT.

 

Funding

Self-funded.

 

Ethics approval and consent to participate

Not applicable.

 

Competing interests

We do not have potential conflicts of interest with respect to the research, authorship, and publication of this article.

 

Availability of data and materials

The datasets used during the current study are available from the corresponding author on request.

 

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (CC BY-NC 4.0).

© 2023 The Author(s).

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Volume 1, Issue 2
July 2023
Pages 95-101
  • Receive Date: 24 March 2023
  • Revise Date: 20 April 2023
  • Accept Date: 28 April 2023
  • First Publish Date: 27 July 2023
  • Publish Date: 27 July 2023